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• <br /> ' Department of Health Services <br /> State of California—Health and Welfare Agency Toxic Substances Control Dlvision <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> 1. Generator's US EPA ID No. an est 2. Page 1 In onnat on n the shad areas <br /> UNIFORM HAZARDOUS p/ ocum t Is not required by Federal <br /> WASTE MANIFEST O of aw <br /> 3. Generator's Name and Mailing Addre s A.Stattt 1At1n Bat trlent Number <br /> bTP <br /> �yNy <br /> o Vww <br /> a s4S}iY ¢3 <br /> 4. Generator's Phone( ) — a <br /> 5. Transp ter 1 Company ame 6. US EPA ID Nu b r q <br /> 7. Transporter 2 Company Name 6. US EPA ID Number - v <br /> nDesited Facility Name and Site Ad ress 10. US EPA ID Number L_Z l IU.A�%, 1,dG,80�' 336 X338' <br /> 9�0 6�a� <br /> 12.Containers 13. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and I D Number) Total unit " 1l,;_f~' <br /> No. Type Quantity uvo <br /> a <br /> E a. <br /> U4Z7 <br /> a <br /> ."2 <br /> E .8• a,: <br /> R v <br /> !S T b. <br /> C. <br /> d. <br /> Descii <br /> 6 OO " <br /> 47 OC) �' h <br /> nl <br /> CDr <br /> CD <br /> 15. Special Handling Instructions and Additional Information <br /> 00 <br /> 16.GENERATOR'S CERTIFICATION.I hereby declare that the contents of this consignment are fully and accurately described <br /> above by proper shipping name and are classified,Packed,marked,and labeled,and are In all respects in proper condition <br /> for transport by highway acc dl g to applicable International gpd cellon I vernmental regulations. Date <br /> L.� Month Day Year <br /> ?nt� ype <br /> Td e_ Signet <br /> i,5 .fJ. ' osr b� <br /> ' Date <br /> 1 17.Transporter 1 Acknowledge ent of Receipt of Materials Month Day Year <br /> A Print Typed Name Sipnalur <br /> 't c •IbnT,bospui tal-.2 Acnnuwiadpament of neCelnt OP:Mater181s `-F' .. .cam'•' <br /> Month Dey Year <br /> T PrintedlTyped Name <br /> Signature <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> It 20.Itemllty Owner or Operator.Certification of receipt of hazardous materials covered by this manifest except as noted n Dete <br /> 199 Month Day.Year <br /> IF Printed/Typed Name Signature <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS 94 eee41 <br /> DHS 8022 A(11/84) To: P.O. Box 3000, Socromento CA 95812 <br /> (EPA 8700-22) <br />